Form to Complete Prior to Menopause Review

Before your visit to the clinic for a menopause review, please complete the following form and submit it prior to your appointment. *Only patients registered with Main Street Clinic will be seen*

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Name *

First

Last

Email *

Phone *

Date of Birth *

When was your last period? *

Are your periods regular?

• Yes
• No

Are your periods painful?

• Yes
• No

Are your periods heavy?

• Yes
• No

Next

PAST MEDICAL HISTORY

Please indicate below if there is any history of the following:

Breast Cancer (Me)

• Yes
• No

Blood clot in a leg or lung (Me)

• Yes
• No

Stroke (Me)

• Yes
• No

Heart disease (Me)

• Yes
• No

Osteoporosis (Me)

• Yes
• No

Migraine headache (Me)

• Yes
• No

Any other cancers? (Me)

• Yes
• No

Breast Cancer (Family)

• Yes
• No

Blood clot in a leg or lung (Family)

• Yes
• No

Stroke (Family)

• Yes
• No

Heart disease (Family)

• Yes
• No

Osteoporosis (Family)

• Yes
• No

Migraine headache (Family)

• Yes
• No

Any other cancers? (Family)

• Yes
• No

Next

Previous pregnancies/gynaecology issues?

When was your last smear?

When was your last mammogram?

When was your last DEXA?

Do you smoke?

• Yes
• No

Do you drink alcohol?

• Yes
• No

How many days a week do you drink alcohol?1234567

Have you used any Hormone replacement therapy before (oral, patch, vaginal)?

• Yes
• No

Please list any regular medications or supplements you take?

Next

Have you had any difficulty taking any hormonal medications before e.g. contraception?

• Yes
• No

Please tick the box if you have noted any of the following symptoms recently.

• Hot flushes / Sweats
• Excess fatigue
• Difficulty sleeping
• Memory or concentration problems ‘Brain fog'
• More aches/pains than usual
• Difficulty losing/maintaining weight
• Breast pains
• Migraine/headaches
• Chest pains or heart palpitations
• Low mood/depression
• Increased anxiety levels
• Loss of interest in sex
• Painful sex
• Unexpected vaginal bleeding e.g. bleeding after sex
• Vaginal dryness
• Needing to pass urine more often or pain on passing urine

Any other symptoms you think may be related to menopause?

Which of the above symptoms bothers you the MOST?---Please select symptom---Hot flushes / sweatsExcess fatigueDifficulty sleepingMemory or concentration problems ‘Brain fog’More aches/pains than usualDifficulty losing/maintaining weightBreast painsMigraine/headachesChest pains or heart palpitationsLow mood/depressionIncreased anxiety levelsLoss of interest in sexPainful sexUnexpected vaginal bleeding eg bleeding after sexVaginal drynessNeeding to pass urine more often or pain on passing urine

Have you tried any complementary/alternative therapies to help with your symptoms?

• Yes
• No

What therapies would you consider? Please tick all that apply.

• Over-the-counter supplements
• Prescribed hormonal replacement therapy (HRT)
• Other non-hormonal prescribed medicines
• Talking therapies

Submit